Plant-based diets are best… or are they?

People choose a vegetarian or vegan diet for a number of reasons. Sometimes it’s out of concern for the way animals are treated or for the environment. But it’s also common to choose a plant-based diet because it’s considered healthier.

And that’s for good reason. Research over many years has linked plant-based diets to lower rates of heart disease, type 2 diabetes, and some cancers (as compared with diets high in meat and other animal products). Dietary guidelines and recommendations from nutrition experts reflect this, encouraging the adoption of diets (such as the Mediterranean diet and the DASH diet) that are heavy on fruits and vegetables and restrict consumption of red meat.

Popular plant-based diets include

• a vegetarian diet, which includes no meat
• a vegan diet, a type of vegetarian diet that excludes not just meat but also animal products, such as milk or eggs
• a pescatarian diet, which is largely vegetarian but also includes seafood.

Plant-based diets carry some risk of inadequate protein, vitamin, and mineral intake. But these risks are readily overcome by choosing the right vegetarian foods and, when necessary, supplements. For example, soy, quinoa, and nuts are good sources of protein, and tofu, lentils, and spinach are good sources of iron.

But a new study, published in the medical journal BMJ, raises the possibility that despite the health benefits demonstrated by past research, plant-based diets could come with a previously unrecognized health risk.

Vegetarians and vegans may have an increased risk of stroke

Researchers in the United Kingdom analyzed the risk of stroke and other health problems over two decades among nearly 50,000 people based on the diets they followed. The types of stroke were also analyzed, including bleeding into the brain (hemorrhagic stroke) and nonbleeding stroke (ischemic stroke). Compared with meat eaters:

• rates of heart disease (such as angina or heart attack) were 13% lower in pescatarians
• rates of heart disease were 22% lower in vegetarians
• rates of stroke were 20% higher among vegetarians. However, the overall risk was small, equal to three extra cases per 1,000 people over 10 years.
• the higher stroke risk among vegetarians was mostly due to hemorrhagic stroke
• the higher stroke risk was not observed among pescatarians.

If confirmed, these findings will complicate the way we look at plant-based diets. Are there serious and underappreciated downsides to these diets that should make us think twice about choosing them? Or is the increased risk of stroke heavily outweighed by cardiac and other health benefits?

This study is also a reminder that the health impact of a particular intervention (such as diet) may not be easy to predict or explain. In most cases, the risk of stroke and heart disease tend to rise or fall together, but that wasn’t the case in this research.

Beware the study’s limitations

This study linking a vegetarian diet with a higher risk of hemorrhagic stroke has a number of important limitations that should temper the concerns of vegetarians.

• The study was observational. That means it simply observed what happened among different people who followed different diets over time, without being able to account for every other relevant factor. For example, if vegetarians chose plant-based diets because of a family history of stroke, it could be their genes driving the higher rates of stroke, not the diet.
• The findings might have been different if the study had included a different study population, such as one with different genetic backgrounds or higher rates of obesity.
• The data regarding diet was self-reported. While the use of dietary surveys is common and necessary in research that requires a large number of study subjects, it isn’t always reliable.
• The study was not large enough to reliably sort out differences in the rates of disease between vegans and vegetarians. As a result, it’s not clear whether the increased stroke risk applies to all vegetarians, or whether vegans might have a different risk.
• We don’t know whether the health outcomes reported in this study might be due to what is included in the diet or what is eliminated. For example, is the lower risk of heart disease among vegetarians due to the plant-based diet, or is it just due to the restriction of animal-based products?

Even so, the results are worthy of our attention — and future study.

The bottom line

If the findings of this new research stand the test of time (and future study), a key question will be: how does a vegetarian diet increase the risk of stroke? Understanding how one’s diet impacts the risk of stroke and other disease will be crucial in future dietary recommendations and other preventive measures and treatments.

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Which is better for reading to your toddler: Print or ebooks?

As we move more and more into a digital age, we use our devices for communication, news, information, games, and so much more. So, it’s natural to reach for a tablet when it comes time to read our child a story. After all, a book is a book, whether it’s print or electronic, right?

Yes — and no. According to a study published in JAMA, there was an observable difference in interactions when parents read their toddlers books on a tablet instead of a print book. The toddlers were less interested and more likely to turn away. In general, they were less engaged.

This is important, because engagement is key for child development. It’s the back-and-forth between the child and caregiver, or “serve and return” as described by the Harvard Center on the Developing Child, that builds neural connections and supports the development of communication and social skills. That “serve and return” doesn’t have to take place while reading a book. It can happen easily through daily conversations and interactive play. But reading books together is a perfect opportunity to help children learn while strengthening the relationship you have with them.

Why are electronic books less engaging to young children?

It’s hard to know exactly what it is about electronic books that make them less engaging than print books. It may be simply that young children like to touch and hold things, and that physically turning pages draws them in more than tapping a screen.

The study was small, only 37 parent-child pairs. The children were young, with a mean age of about 2.5 years. It’s hard to know what a bigger study with a wider range of ages might show.

Reading makes a difference, in print or ebooks

The most important thing isn’t really what kind of book you read to your child, it’s that you read to your child. Whether it’s print or electronic, here are some ways to engage your child and get the most out of the experience:

• Don’t just read the words. Comment on the story, and ask your child questions about it (“Would you like to do that? Does he look happy or sad? What do you think will happen next?”)
• Have your child point things out on the page (“Where is the dog?”)
• Relate it to your child’s experience (“We have a swing like that at the park! Do you remember when I pushed you on it?”)
• Look for books that have predictable repetition to them (books by Eric Carle are a good example), and encourage your child to “read” along with you.
• Share the holding of the book and turning pages. If the book is a shared object, rather than just something the grownup holds and controls, it can be more interesting to the child.

Follow me on Twitter @drClaire

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Bisexuality and health: The cost of invisibility

On September 23, 2019, the 20th anniversary of Bi Visibility Day, the National Institutes of Health (NIH) held its first-ever bisexual health research workshop. As an invited panelist at this event, sponsored by the NIH’s Sexual and Gender Minority Research Office, I joined 19 other researchers to discuss key findings, gaps in knowledge, and future directions.

You may be asking yourself: Is there really a need for this workshop? How is bisexual health different from the health of other groups? How many people even identify as bisexual?

What is bisexuality?

Robyn Ochs, a prominent bisexual activist and writer, defines bisexuality as “the potential to be attracted — romantically and/or sexually — to people of more than one gender, not necessarily at the same time, not necessarily in the same way, and not necessarily to the same degree.” People don’t have to identify with the label “bisexual” to have a bisexual orientation.

Bisexuality can mean having attractions to or sexual behavior with people of more than one sex or gender — for example, feeling attracted to both women and men. Some people have a range of “nonmonosexual” identities — that is, identities that go beyond heterosexual or lesbian/gay — including pansexual and queer. Some people have more than one identity (I identify as both queer and bisexual). The preferred umbrella term for anyone with a nonmonosexual orientation is “bi+.”

Who is bi+?

People identify as bi+ across genders, races/ethnicities, socioeconomic groups, and ages, but some groups (people of color, adolescents, and transgender people) are more likely to identify as bi+. It may come as a surprise to learn that bi+ people are the largest sexual minority group. Among adolescents, more people identify as bisexual than identify as either lesbian or gay. Among adults, bi+ people represent a substantial part of the population. But despite these numbers, there is less research on bi+ health and less available funding for research, compared with research on lesbian and gay people.

How might being bi+ affect health?

If you’re bi+, a 2019 study of people of different sexual orientations and racial/ethnic backgrounds found that you may be more likely than people with other sexual orientations to experience certain health problems. For example, gastrointestinal problems, arthritis, and obesity occur more often among bi+ women and men. Additionally, women who are bi+ may have a poor health-related quality of life, while bi+ men may have high cholesterol, high blood pressure, and cardiovascular disease.

If you’re bi+ and you’re also a woman or a transgender person, your risk for poor health — including substance use, depression, and suicide — climbs even higher compared with other bi+ people (see here and here).

Why are bi+ people more likely to experience poor health?

Experts in the field of bisexual health research believe minority stress negatively affects health outcomes. Minority stress refers to experiences of prejudice or discrimination based on stigma that lead to poor health. Bi+ people experience unique minority stress related to being bisexual, such as negative stereotypes about what it means to be bisexual (bisexuality is a phase, bisexual women are promiscuous, bisexual men are vectors of HIV). Feeling invisible may also create problems. These unique forms of minority stress can be harmful for bi+ people’s health.

• Bisexual invisibility can affect the quality of medical care. A bisexual woman who is in a relationship with a woman, but also has sex with men, may not be offered birth control or counseling about sexually transmitted infections (STIs) at a doctor’s appointment, because she is (incorrectly) assumed to be a lesbian and not at risk for pregnancy or STIs.
• Double discrimination can harm mental health. Bi+ people experience discrimination from both heterosexual and sexual minority communities, related to repeatedly needing to “come out” as bi+. This double discrimination can lead to isolation and loneliness, which can be harmful for mental health.

What steps can you take to counter these issues?

If you are bi+, you can improve your health by

• connecting with others who are supportive of your bisexuality, including people who are also bi+ and can understand the unique stresses that bi+ people sometimes face
• being honest with your doctor or mental health provider about your bisexuality, so that you can get the care you need.

Even if you are not bi+ yourself, you can support bi+ people by

• examining your biases and assumptions (for example, not everyone with a different-gender partner identifies as heterosexual) and educating yourself about bi+ people
• educating others about bi+ people to challenge stereotypes and reduce stigma, to increase acceptance of the bi+ community.

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Hope and caution during infertility treatment

Many years ago, I worked for a reproductive endocrinologist who hosted a yearly gathering of former patients. It was there that I encountered a woman holding infant twin daughters. When I congratulated her on her twins, she had these thoughts to share: “I’m a psychiatrist and I hope you’ll pass this on. Please tell people not to worry about being positive and hopeful. I abandoned hope and went through my last IVF cycle as the queen of negativity.” Then she held up her twins and said, “And this is what I got. Please reassure people that they don’t have to stay positive.”

Over the years, I have come to believe that managing hope is a major challenge during infertility treatment. This story illustrates one facet of the challenge: does it matter if one is hopeful during a treatment cycle? Some patients work very hard to remain positive and to nurture hope, while others, like the mom in the story, ride a wave of negativity. People in both groups have healthy pregnancies. And sadly, there are members of both groups who meet repeated disappointment.

Managing hope is even more challenging when it comes to the big picture, looking beyond a specific cycle and to the question of when enough is enough. During infertility treatments, there are people who remain hopeful when odds are against them and others who lose hope when test results and medication responses seem promising.

Managing hope during infertility

A few factors that contribute to or reduce your sense of hopefulness are:

Personal history. Some people come to infertility with a history of good luck and good fortune, an abiding belief that things work out for them. Their history fuels their hope.

Determination. Threaded throughout the infertility population are some pretty determined people. These hard workers have been rewarded for their efforts on the job and in other areas of their lives. They assume that if they read extensively on infertility, research the best doctors, eat a “fertility diet,” and incorporate appropriate alternative treatments, they will succeed in having a baby.

Doctor-patient relationship. Communication between doctors who treat infertility and their patients plays a significant role in fueling or deflating hope. Good doctors do their best to promote an appropriate level of hope. They believe that doing right by their patients means helping them pursue treatment that has a reasonable chance of working, and helping them leave treatment that is unlikely to work. Sadly, there are times when people remain in unsuccessful treatment because their doctors are reluctant to be the bearers of bad news.

Fellow travelers and faith

Fellow travelers. Infertility patients cope with the stresses of infertility by finding each other. Waiting rooms, support groups, and online chats all connect infertility patients. While it can be painful to learn that a fellow infertility traveler has become pregnant against all odds, this sort of news fuels hope. Alternatively, seeing a fellow infertility traveler move happily on to adoption or egg donation can redirect hope. An option that once seemed like “what you do when you give up” now brings new possibilities.

Faith. Faith and spirituality nurture hope for some infertility patients. The nature of this hope may shift from the hope that comes from believing that prayers will be answered, to the hope that comes from believing that some things are meant to be. Guided by faith, these infertility patients have an abiding sense that there are forces beyond them ensuring a safe and positive outcome of this journey.

In working with individuals and couples trying to manage hope and caution as they enter a first or second or fifth IVF cycle, I am always careful to leave it to them to gauge hope. Over the years, it has been humbling to see some people achieve the most unlikely pregnancies while others are mired in disappointment.

These experiences have left me with a profound respect for people’s ability to titrate optimism and caution as they make their way through infertility. There are times when a bounty of hope feels right. At other times, infertility travelers need to shelter themselves with caution. This was my takeaway message from the psychiatrist mom I met at that gathering so long ago.

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Think your child might have a disability or developmental delay? Take these steps

While we all want our children not to have any problems at all, the reality is that life doesn’t always work that way. Many children suffer from some sort of problem, whether it’s something minor and often temporary, like a speech delay, or something more difficult and permanent, like cerebral palsy or autism.

Children with problems or disabilities are no less wonderful and deserving than children without. The key to getting them on the right path for the best life possible is identifying those problems and getting help — as early as possible. That’s why it’s important to speak up early. Sometimes there isn’t a problem, and a child just needs a bit more time, or is a bit quirky. But it’s always better to find out. You have nothing to lose and everything to gain.

Taking the first steps to evaluate possible disability or developmental delay

The first step if you are worried about your child is to share those concerns with your health care provider. There may be medical tests that are needed or could be helpful, and your doctor can and should be your partner in helping your child and your family.

The next step is getting your child an evaluation. This will connect you to any help and services that may be needed. Ask your doctor about suggestions for specialists who can evaluate your children. Two kinds of evaluations are available to all children:

• Early Intervention for children from birth to the third birthday
• Individualized Educational Plan (IEP) for children who have turned 3.

What is Early Intervention?

This is a service for children from birth through their third birthday who either have a problem with their development or are at risk for one (for example, babies born prematurely). To find out if a child is eligible, a skilled team does an evaluation. Usually this takes place in the child’s home, but can also take place at daycare or another place where the family feels more comfortable. Your doctor can refer you to Early Intervention, or a family can self-refer by reaching out to a local Early Intervention program to say that they are worried about their child’s development and would like to arrange an evaluation.

If a child is found to have a developmental problem, the team works out a service plan with the family. Children meet regularly with a developmental specialist, and there are other services, such as physical therapy, that can be brought in as well. Early Intervention works not only to provide services, but also to help the family help the child, giving them skills and strategies to support their child’s development.

The evaluation is always free, but it varies from state to state as to whether services are free. Early Intervention gets funding from both the government and insurance companies. In many states, all services are free. In some states, families are charged a sliding-scale fee based on their income.

What is an Individualized Educational Plan?

Once children turn 3, the responsibility for an evaluation and services shifts to the public schools. These evaluations are also free and available to all children. To get one of these evaluations, parents should go to their local school district and say that they are concerned about their child’s development and would like an evaluation. If they aren’t sure where to go, they can ask at any school in their district.

Next, the school district will discuss and plan with them what kind of evaluation should be done, because there are many possible aspects to an IEP evaluation. The doctor can help with this, for example, by suggesting an evaluation by a physical therapist, or testing for a learning disability.

After the evaluation, the team holds a meeting to discuss their findings with the family and anyone else the family wishes to include. If they identify any issues, the team will propose a plan for services and help. The family doesn’t have to agree at that moment to the plan. They can think about it and propose changes before signing it. It’s always a good idea to show the IEP evaluation and proposed services to your doctor and discuss it together.

Sometimes, while a child might not qualify for special education services, they need adjustments in their school program or extra support because of a diagnosis or disability. Examples might be a child with ADHD who needs extra time and help on assignments, or a child with a visual problem who needs to sit close to the front of the room and have access to larger print or other visual aids. For these children, the school, family, and doctor work together to create a 504 plan to meet the child’s needs.

The bottom line

If you have any worry that your child might have a disability or problem with their development, ask for help. There is help available, and the sooner you ask for it, the better for your child.

Follow me on Twitter @drClaire

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Can exercise help treat anxiety?

Chances are good that you, or someone you know, is dealing with anxiety. One in five Americans over 18, and one in three teenagers 13 to 18, reported having a chronic anxiety disorder during the past year. And when I talk to college students, they’re not at all surprised that a whopping 63% of students felt tremendous anxiety during their freshman year, according to a report by the National College Health Association.

The toll of anxiety can be high: it increases a person’s risk for other psychiatric disorders like depression, and can contribute to diabetes and cardiovascular problems. One sobering study shows that people with anxiety tend to be more sedentary and do less intense forms of physical activity, if any. That’s ironic, because lacing up your sneakers and getting out and moving may be the single best nonmedical solution we have for preventing and treating anxiety.

As a psychiatrist who studies the effects of exercise on the brain, I’ve not only seen the science, I’ve witnessed firsthand how physical activity affects my patients. Research shows aerobic exercise is especially helpful. A simple bike ride, dance class, or even a brisk walk can be a powerful tool for those suffering from chronic anxiety. Activities like these also help people who are feeling overly nervous and anxious about an upcoming test, a big presentation, or an important meeting.

How does exercise help ease anxiety?

• Engaging in exercise diverts you from the very thing you are anxious about.
• Moving your body decreases muscle tension, lowering the body’s contribution to feeling anxious.
• Getting your heart rate up changes brain chemistry, increasing the availability of important anti-anxiety neurochemicals, including serotonin, gamma aminobutyric acid (GABA), brain-derived neurotrophic factor (BDNF), and endocannabinoids.
• Exercise activates frontal regions of the brain responsible for executive function, which helps control the amygdala, our reacting system to real or imagined threats to our survival.
• Exercising regularly builds up resources that bolster resilience against stormy emotions.

The details

So exactly how much exercise does one need to protect against episodes of anxiety and anxiety disorders? While pinpointing this is not easy, a recent meta-analysis in the journal Anxiety-Depression found that people with anxiety disorders who reported high-level physical activity were better protected against developing anxiety symptoms than those who reported low physical activity. Bottom line: when it comes to treating anxiety, more exercise is better.

If you’re just starting out, don’t despair. Some research also shows that just a single bout of exercise can help ease anxiety when it strikes.

Which type of exercise you choose may not matter greatly. Studies point to the effectiveness of everything from tai chi to high-intensity interval training. People experienced improvement no matter which types of activity they tried. Even general physical activity is helpful. The important thing is to try activities and keep doing them.

To maximize the benefits:

• Choose something enjoyable so you will do it repeatedly, building resilience.
• Work toward getting your heart rate up.
• Work out with a friend or in a group to reap the added benefit of social support.
• If possible, exercise in nature or green space, which further lowers stress and anxiety.

While scientific studies are important, you don’t need to consult a chart, statistics, or an expert to know how good you feel after working up a sweat. Remember those feelings and use them as motivation to do something physical every day. Time to get up and get moving!

Follow me on Twitter @jratey

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Making young minds resilient to disasters

As a pediatrician and a parent, I often think about what I’d do to keep my children safe if we were hit by a storm like Hurricane Dorian, which reduced whole towns in the Bahamas to rubble. Or by a wildfire, like the Camp Fire that burned the town of Paradise, California to the ground. Or how we’d deal with this year’s record-breaking rains that flooded scores of towns throughout the Mississippi River Basin.

Disasters like these — which may be getting more dangerous with climate change — can directly harm a child’s body. But what’s less well appreciated is how they can harm our children’s minds, and how these harms can result in poorer health across our children’s lives. Fortunately, we can take actions to build resilience in our children and in our communities before a disaster strikes, which may help buffer them from the trauma of living through one.

How might children experience a natural disaster?

We can take concrete steps to protect our homes and families from the imminent risks that come with natural disasters. But even if our homes are spared, and we have enough food, water, and backup power to keep our families safe, a child who lives through a major disaster can have lingering health effects that may be difficult to see at first.

So, for a moment, imagine the sense of loss — and instability — a child might feel when they return home after a disaster. Their community isn’t the one they knew just a few days before. Their school, the homes of friends and family, the places they used to play, may all have vanished. None of these losses may be as unsettling as finding their home destroyed, or learning that a loved one has died.

Trauma from hurricanes, wildfires, and floods can have long-term mental health impacts on children. Researchers have found that children who experience these natural disasters can suffer from lingering anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms (also see here and here). As many families learn, post-disaster signs of PTSD in children may include recurring upsetting dreams, separation anxiety, and physical responses such as headaches and stomachaches.

And they also may be at risk for worse health in other ways.

What are adverse childhood events and how do they affect health?

Adverse childhood events (or ACEs) refer to a range of traumatic events, such as:

• physical abuse or neglect
• parental mental illness
• divorce
• exposure to violence
• living through a natural disaster.

ACEs can lead to toxic stress, which can result when a child has to endure many adverse events and lacks adequate protective buffers. Recurrent or prolonged triggering of a child’s stress response can alter brain architecture. It also affects development of other organs, with health consequences that stretch into adulthood, including higher rates of substance use, unwanted pregnancies, cancer, and HIV.

How can we help children build protective resilience?

But we can buffer children from ACEs and the toxic stress that drives poorer health outcomes. For instance, one of the most powerful forces in preventing damage from toxic stress is having a supportive adult in a child’s life. Many other actions can bolster resilience by helping them feel confident in their ability to adapt to change. This can include anything from promoting healthy risk-taking and encouraging children to do things that are outside their comfort zone, to modeling perseverance in the face of adversity by adults. Several practical guides for parents on building resilience to ACEs and toxic stress are available from trusted authorities such as the American Psychological Association and the American Academy of Pediatrics.

With the right tools, parents, teachers, coaches, and religious leaders, among others, can all contribute to building a child’s resilience. So, too, can communities and local governments. Access to high-quality early education, crime prevention, professional development for teachers, parental coaching on responding to children’s emotions, better parks and playgrounds, and possibly even increased exposure to green space may all be investments that create lifelong payoffs by buffering children against toxic stress.

With eye-popping climate change disasters unfolding before our eyes, we must not miss the sometimes harder-to-see effects that can emerge and persist long after the storms and fires are over. We must do what we can to prepare ourselves, and our communities, to make our children stronger and more resilient.

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Preventing falls in older adults: Multiple strategies are better

Despite considerable research and clinical effort, falls among people 65 and older are on the rise. An older adult is treated in the emergency room for a fall every 11 seconds, with injuries ranging from simple cuts and bruises to broken bones. Hip fractures are the most serious injury from falls, and more than half of older adults hospitalized for hip factures after a fall never regain their previous levels of mobility or quality of life. Further, falls are a leading cause of death among older adults. According to the Centers for Disease Control and Prevention, an older adult dies from a fall every 19 minutes. Despite these sobering statistics, falls are not an inescapable part of aging; on the contrary, most falls are largely preventable.

Falls are particularly hard to study — and prevent — because no two falls are the same

Over the years I have interviewed hundreds of older adults who had recently suffered a fall, and one thing is clear: each fall occurs from the unique interaction of the person’s balance, the task they were performing just prior to the fall, and the ever-changing environment in which they were moving. All these things make it difficult to pinpoint the exact cause of a particular fall, and nearly impossible to uncover commonalities across all falls suffered by older adults.

The complexity of falls may be the key to their prevention

It is now quite clear that fall-prevention strategies that target just one factor with a well-known link to fall risk, such as muscle weakness, do not effectively reduce falls in older adults. Instead, researchers now believe that in order to keep older adults safe and free from falls over the years, interventions must continuously target multiple individual and environmental factors.

This current viewpoint is perhaps best highlighted by the ongoing STRIDE clinical trial. This pragmatic trial has enrolled 86 primary care practice sites across the country and over 5,400 older adults who are at risk for falls. The aim of this study is to compare the effectiveness of the current standard of care (which is primarily education about fall prevention) with individualized interventions developed by nurse “falls care managers” working in collaboration with primary care physicians. The falls care manager first assesses the older adult for eight key modifiable risk factors for falls and fall-related injuries: strength and balance, medications, vitamin D deficiency, home safety, orthostatic hypotension, visual impairment, foot problems and footwear, and osteoporosis. They use this information, together with personal preferences from each participant, to devise and implement an individually-tailored intervention that combines strategies for the older adult, recommendations for their doctor, and even referrals to health providers and local community-based organizations to support certain aspects of the intervention.

The STRIDE trial is closed to enrollment; however, data collection and analyses of its effectiveness are still underway. In the meantime, here are five specific actions you can take to minimize risk factors for falling.

• Make exercise part of your daily routine. According to the Harvard Medical School Special Health Report Better Balance, tight, inflexible, or weak muscles together with poor posture and endurance impinge on balance and can lead to falls. Regular, clinician-approved exercise can help counteract each of these factors. A recent analysis in the Cochrane Database of Systematic Reviews concluded that regular exercise may reduce the rate of falls by 23%, and the number of people who fall by 15%.
• Stay mentally active. Researchers have recently identified cognition as a key player in balance and fall risk. This is because we must pay attention to the world around us, avoid distraction, “remember” where our body is in space, and make the right decisions to modify our movements when our environment changes unexpectedly. It is for these reasons that staying mentally active, and participating in mind-body exercises such as tai chi, yoga, or dance, have been shown to be particularly effective fall-prevention strategies for older adults.
• Review your medications. Discuss all of your medications with your doctor and use them strictly as prescribed. Be aware that some medications have side effects (drowsiness, dizziness, muscle weakness, etc.) that may alter your balance and lead to a fall.
• Have your vision and hearing checked regularly. We depend on our vision and hearing to maintain our balance as we move through each day. Wearing glasses and hearing aids when prescribed can reduce the likelihood of balance issues and falls.
• Conduct an annual home inventory. Reorganizing the bedroom, kitchen, living room, and other common areas according to your needs is also important to reduce falls and/or prevent them from recurring over time. For example, keep medicines, clothing, food, dishes, and other necessities for day-to-day living within easy reach. Avoid scatter rugs and remove low-rise furniture, such as coffee tables and bookcases, that may clutter direct access to doors, hallways, and windows. Light the way day and night with lamps by the bed and nightlights in each room, and install light switches by all doors. Handrails on both sides of the stairs and grab bars for the shower and toilet are essential.

It is also important to remember that falls have a significant impact on your quality of life, whether they cause injury or not. Just the fear of falling can cause loss of confidence and depression, which can lead to isolation and anxiety as older adults withdraw from outside activities or social engagements. Implementing multiple preventive measures early and evaluating them often can facilitate your mobility, reduce your chances of losing balance, and help maintain your quality of life for years to come.

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Is it time to stop skimming over full-fat dairy?

Americans consume about 150 pounds of milk and eat nearly 40 pounds of cheese and 20 pounds of ice cream per person per year, according to data from the Department of Agriculture. Yogurt and butter intakes are lower, but growing. But should the dairy we’re consuming be low-fat or full-fat? That debate has become increasingly divisive, and for good reason: not all dairy is created equal.

Dairy fat and cardiovascular disease

Some of the most substantial dairy research has been done in the context of the Dietary Approaches to Stop Hypertension (DASH) diet, which has been shown, among other benefits, to reduce blood pressure and lower cholesterol, both risk factors for cardiovascular disease (CVD). Along with promoting heart-healthy fats and fiber-rich foods, the DASH dietary plan recommends two to three servings per day of low-fat or fat-free dairy, primarily from milk, yogurt, and cheese. The vitamin and mineral content in these items, plus protein compounds called peptides, are believed to play a role in protecting the heart. Probiotics in fermented dairy products, like yogurt, have also been shown to improve blood pressure, and have been associated with decreasing CVD risk.

More recently, however, research has suggested that dairy need not be stripped of its fat. Some studies have indicated full-fat sources may not play a role in CVD-related deaths, and might even be protective in some cases.

This is not a call to arms for butter. Though recent data did not show an association between dairy fats and CVD, certain types of dairy fat were still correlated with an increased overall risk of death. Eating high-fat dairy, like butter, has also been associated with an increased risk of dementia. A little butter on toast is likely fine, but more than a tablespoon a day may still be risky. Using butter as your main cooking fat is still not advisable.

Dairy fat and cancer

This issue becomes a little more complex when looking at dairy and cancer risk. Some research has associated higher-fat dairy sources with worse breast cancer survival rates, for instance.

The problem with these studies is that different types of dairy products often get lumped together, meaning full-fat yogurt, cheese, cream, and ice cream are treated as equals.

No one would claim whole-milk yogurt and cookie dough ice cream to be equivalent, and we should take care not to view them as such. In fact, some studies suggest that fermented dairy foods like yogurt may reduce cancer risk, but more information is needed to tell whether the type you choose matters.

Dairy fat and body weight

When it comes to weight, full-fat dairy has been correlated with a decreased risk of obesity. One possible reason is that the fat found in whole milk or a wedge of Brie helps with satiety. Intuitively, this makes sense too. If something has a richer flavor, you may need less of it to feel satisfied.

We now know that being too restrictive about dietary fat may not be a helpful strategy for maintaining a healthy weight, particularly if it does not feel sustainable. It’s also possible that individuals avoiding high-fat foods may be more likely to suffer from a restrictive dieting mentality, possibly contributing to weight-related struggles later in life.

Choose wisely if opting for full-fat dairy

 At the end of the day we can rely on a little common sense: the type of full-fat dairy you choose likely matters. Prioritizing fermented sources of full-fat dairy may be the way to go. Having a little cheese — or better yet, some whole-milk yogurt — might even offer benefits in certain cases. Having them alongside fruit or nuts (rather than on a slice of pizza or sweetened with sugar) would be even smarter.

As for ice cream and butter? They have perks too, namely the pleasure that comes from eating them.

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Recurrent headaches in children: What to know and do

Headaches are very common in children. By the time they reach 18, essentially all kids will have had at least one. Most children get them rarely, usually with an illness. But some children get recurrent headaches. About 5% of kindergartners experience this problem, and the percentage goes up as children get older. By the time they get to the end of high school, that number is up to more than 25%.

Recurrent headaches often run in families. There are two types: primary and secondary. Primary headaches come from the nervous system itself, while secondary headaches are caused by something affecting the nervous system, such as an illness.

Migraines and tension headaches

Migraine and tension headaches are the two most common primary headaches in children.

• Migraines cause pain that a child can point to, usually on both sides of the head. It is throbbing and gets worse with activity. Light and noise can make it worse, and children will sometimes have nausea or vomiting. About 10% of children also have an “aura,” meaning that before the headache they have changes in their vision, like blind spots or sparkling lights, or other things like weakness or tingling.
• Tension headaches tend to be all over and less easy to point to. They don’t throb like migraines or get worse with activity. As with migraines, light and noise can make them worse. However, they don’t cause nausea or vomiting, and there isn’t an aura.

What causes secondary headaches?

The most common cause of secondary headaches is illness, like a bad cold or the flu. Other common causes include bumps to the head (from a little knock to a concussion) and side effects of medicines. Kids can also get headaches from taking over-the-counter pain medications too often — more than three or so times a week — which many parents don’t realize. There are more serious causes of secondary headaches, like high blood pressure, tumors, or increased pressure on or bleeding in the brain, but those are very rare.

What should you do about recurrent headaches?

If your child is having recurrent headaches, call your doctor. Even though it’s likely to be nothing serious, your doctor should know about it. Keep a diary of the headaches: what they are like, any symptoms that happened at the same time, the medicines you gave, and what was going on that day. This will help you and your doctor figure out what to do.

Acetaminophen and ibuprofen can help in the moment, but don’t immediately reach for medicine unless your child is very uncomfortable. Not only can giving pain relievers too frequently make things worse, but much of the time medicine isn’t needed. Have your child rest, perhaps with a cool cloth over their eyes. Get them something to drink (water is fine) and something light to eat if they haven’t eaten in a while.

Preventing recurrent headaches

To help prevent recurrent headaches, make sure your child

• gets enough sleep (eight to 10 hours a night)
• gets daily exercise
• eats and drinks regularly throughout the day.

Stress can cause headaches, so be mindful of your child’s stress level. Keep lines of communication open, and make sure that your child has downtime every day to relax and do whatever makes them happy.

To learn about when headaches in children can be a sign of a problem, check out 8 things to watch for when your child has a headache.

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Is there really a blood test to diagnose concussion?

In the past year and a half, various news stories may have led some people to believe that there are blood tests that can diagnose or unmask concussions with a single drop of blood. For individuals who have recently received a bump, hit, or jolt to the head and are wondering if they have sustained a concussion, this may sound like a simple way to find out. Unfortunately, for now it probably isn’t.

What do these blood tests actually do?

Simply put, these tests measure substances, such as proteins and enzymes, that are released into the blood within hours of a brain injury when there is intracranial damage (including bleeding in the brain). Such brain damage is often observable via a CT (computed tomography) or MRI (magnetic resonance imaging) scan. If the levels of these substances are below certain cutoff values, this suggests that no such observable intracranial damage has occurred, and a scan can be safely avoided. Therefore, these tests hold promise for avoiding unnecessary imaging scans, saving on medical costs, and — importantly — avoiding unnecessary radiation exposure from CT scans. As these tests evolve, they may prove to be more sensitive than CT scans at determining intracranial damage.

What happens when a person seeks treatment for a traumatic brain injury (TBI)?

When someone experiences a trauma to the head and a possible brain injury is suspected, they are often taken to a trauma center or ER. Physicians need to determine fairly quickly whether the person is safe to go home, or if a patient requires a brain scan to identify more serious and/or potentially life-threatening injuries to the brain, such as bleeding. In moderate to severe TBIs, the need for imaging is fairly obvious. However, when someone has symptoms of a mild TBI (also called a concussion), the need for a CT scan, the type of scan most typically performed in these cases, is much less clear.

In a majority of mild TBI cases, a CT scan finds no abnormality and is ultimately unnecessary for many people. CT scans are expensive, not always practical or possible, and expose patients to radiation that is preferably avoided. It would be ideal if unnecessary CT scans could be safely prevented without doctors missing a more serious brain injury. Here is where a blood test may be useful: rather than undergoing a CT scan, if a person has this blood test and shows no increase in the proteins and enzymes that indicate intracranial damage, then they can forego the CT scan and should be safe to go home. One estimate is that up to about a third of unnecessary scans may be avoided by using a blood test. However, if used in a way to confirm the presence of a concussion, current TBI blood tests would result in many false negatives, meaning that the test would say there was not a concussion when there really was one.

How do you know if you’ve suffered a concussion?

A concussion is a mild form of a TBI. There is no single definition, but many medical groups agree that a concussion typically involves some type of hit, jolt, or other force that causes the brain to smash inside the skull and cause a change in consciousness. A person might experience blacking out (even very briefly), some loss of memory surrounding the event, or a period of feeling dazed, disoriented, or confused immediately after the injury. Simply put, if a person suffers a blow or force to the head that causes any of these changes in consciousness, then a concussion has occurred.

In most cases, there will be no visible signs of injury to the brain on a CT scan. Positive imaging findings, i.e., CT or MRI findings that do show damage to the brain, are not required for a diagnosis of a concussion. Although there is damage, the damage that occurs to the brain in a simple concussion is typically not detectable on a CT scan. So a TBI blood test may be useful in trying to indicate if something more than a simple concussion has occurred, but it will not tell you — at least not yet — whether you sustained a simple concussion.

This is important to recognize because, even in the absence of visible damage to the brain after a concussion, and/or a negative TBI blood test, patients still may have symptoms related to such a concussion, which include headaches, nausea, dizziness, memory or concentration problems, and mood changes.

TBI blood tests may hold promise for reducing radiation exposure from CT scans, and they are also evolving to have other promising uses. Currently a blood test is not the answer to determining whether you have a concussion. What is important to note is that if you do have a concussion, you follow the protocols recommended by your doctor.

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If you are happy and you know it… you may live longer

Plenty of research suggests optimistic people have a reduced risk of heart disease, stroke, and declines in lung capacity and function. Optimism is also associated with a lower risk of early death from cancer and infection. And now a new study links optimism to living a longer life.

What does this new research on optimism tell us?

The study in Proceedings of the National Academy of Sciences found that people who had higher levels of optimism had a longer life span. They also had a greater chance of living past age 85. The researchers analyzed data gleaned from two large population studies: about 70,000 women from the Nurses’ Health Study and about 1,400 men from the Veterans Affairs Normative Aging Study.

The Nurses’ Health Study used items from the Life Orientation Test to assess optimism. The measure asks respondents to rate their level of agreement to several statements about optimism. The Normative Aging Study relied on the Optimism-Pessimism Scale, administered as part of a personality assessment. This scale examines the positive and negative explanations people give for events in their life.

For both men and women, higher levels of optimism were associated with a longer life span and “exceptional longevity,” which the researchers defined as surviving to 85. The study controlled for factors like chronic physical conditions (such as hypertension or high cholesterol) and health behaviors (such as smoking or alcohol use).

There were several limitations to the study results. For example, participants were largely white and had higher socioeconomic status than the general population. These factors may limit whether the findings apply to a wide range of people.

So why might optimism affect longevity? The study wasn’t designed to explain this, but the researchers had several thoughts. While one component of optimism appears to be heritable — that is, tied to our genes — our environment and learning also shape a significant portion. One takeaway is that we can all learn ways to be more optimistic.

How can you become more optimistic?

Whether you’re naturally optimistic or not, you can take certain steps in that direction.

• Reframe situations. When some people confront difficulties, they tend to only view the negative aspects of the situation. Also, they consider these aspects unchangeable. To reframe a difficult situation, search for any positive aspects or silver linings. Is there anything you can learn from the situation? Is there anything you can teach to others about the situation, after you resolve it?
• Set goals. Set achievable goals for each day and adjust those goals as needed. Be specific and realistic. For example, rather than a broad goal, such as “clean house,” identify specific areas that you plan on cleaning (wipe down counters, scrub kitchen sink). Research suggests that setting goals and having the confidence to achieve these goals is related to optimism.
• Set aside time to focus on the positive. At a set time each day (perhaps at bedtime), think about the positive aspects of your day. What went well? What are you happy about? What are you proud of?
• Practice gratitude meditations. Gratitude meditations focus on giving thanks for the positive aspects of your life, which can include family members, friends, or possessions, among other things. You can find numerous scripts and guided meditations available online.
• Strengthen social relationships. The researchers noted that optimism is related to strong social networks. A strong social network can include spending time with close friends, or participating in regularly scheduled group or community activities. Joining new groups or scheduling time to see friends and family and engage in activities strengthens these relationships. Focus on spending time with positive and supportive people.
• Practice the half-smile. A psychotherapy technique to cope with sad feelings is to practice smiling for a few minutes each day. If a full smile is not possible, a half-smile works as well. Notice any impact on your thoughts, mood, and level of optimism.

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Harvard Health Ad Watch: A new treatment for knee arthritis

The TV ad promises pain relief for knee osteoarthritis, the source of most of the 600,000 knee replacement surgeries performed in the US each year. A man in a bowling alley winces with pain. He nearly falls as he rolls a ball into the gutter. (Did I mention the arrow sticking out of his knee?)

“Knee acting up again?” asks his buddy, clearly concerned. When pain pills don’t seem to help, his buddy suggests a procedure called Coolief for knee osteoarthritis.

“I had it done six months ago,” says the bowling buddy. “And the best part is that it lasts up to one year.”

What is Coolief?

Coolief is a procedure, not a pill. A doctor inserts electrodes through the skin, placing them near nerves in several locations around the knee. Electric current applied through the electrodes delivers heat to the nerve. This impairs its ability to send pain signals to the brain.

Standard nerve blocks use a similar method to block pain signals. But Coolief doesn’t just heat up the electrodes, it cools them down – a technique called “cooled radiofrequency ablation.” The idea is to deliver more energy where it’s supposed to go with less collateral damage.

The procedure is considered minimally invasive. However, it requires several injections and x-ray guidance to be sure of the proper location. By comparison, a cortisone shot in the knee to relieve pain is usually only one injection, and x-ray guidance is rarely needed.

Does Coolief work?

A number of studies have tried to answer this question, but the evidence is iffy. According to a recent review of previous research, the evidence supporting cooled radiofrequency ablation as a reliable and long-lasting way to relieve pain from knee osteoarthritis is quite limited. Many studies included only a few patients and did not assess response after more than a few weeks.

Here’s a quick rundown of some of the largest and most recent studies:

• A 2015 study of nine people with osteoarthritis receiving cooled radiofrequency ablation reported improvement in measures of pain and function “beyond one year,” but specific details, including how many people improved, were not provided.
• A 2017 study of 33 people found a success rate of only 35% six or more months after treatment.
• A 2018 study of 151 people compared cooled radiofrequency ablation to having a single cortisone shot. After six months, 74% of people who had the procedure reported a reduction in pain by at least half. A similar improvement was reported by only 16% of those receiving a cortisone injection.

What else should you consider?

Most studies found few or no side effects associated with the Coolief procedure. Even so, the manufacturer warns of potential risks that include infection, nerve damage, increased pain — even paralysis and death. In part, this may be based on reports of cooled radiofrequency ablation in other areas of the body.

One downside that’s worth emphasizing is cost: according to an NBC News story about this treatment, it can cost $2,000 to $4,000, and may not be covered by health insurance.

Are the ads accurate?

Based on the 30-second TV commercial described above and a six-page online brochure, some of the claims seem exaggerated, misleading, or incomplete. For example:

• A major marketing point of Coolief is that it lasts up to a year. Yet, evidence showing such long-lasting improvement in pain, function, and quality of life is quite limited. I could find only one published report (the 2015 study mentioned above) that monitored treated individuals for a year. It followed only nine patients, three of whom had already had knee replacement surgery. No details were provided on how long improvements lasted for individual patients. Also, the study cited by the online ad as evidence for the one-year claim actually monitored patients for only 12 weeks. Another study of long-term results is “available upon request” from the company marketing Coolief.
• Some evidence cited to support using Coolief for osteoarthritis of the knee comes from treatment of hip and spine pain. One study cited as proof of long-term benefit did not even use cooled radiofrequency ablation — it used a standard nerve block. And lasted only 12 weeks.
• The online ad repeatedly reminds the reader that Coolief is not an opiate, and that we need non-opiate options to treat pain given the risks and side effects of opiates. That’s true. But other statements aren’t true. Opioid prescriptions are notgiven to patients as a first-line treatment for chronic pain. Nor has relief from osteoarthritis knee pain relied on a daily regimen of prescription opioid medication. In fact, because osteoarthritis of the knee tends to affect older adults who are prone to medication side effects, and because opiates come with a host of risks and side effects, physicians tend to avoid opiates in these patients.
• The online ad describes the Coolief procedure as “minimally invasive” and cortisone injections as “invasive.” In fact, they are both minimally invasive.

Finally, learning that Coolief was “cleared” by the FDA might lead you to assume the FDA evaluated the evidence and concluded this procedure is safe and effective. In fact, Coolief did not require specific FDA approval because the FDA concluded it was similar enough to other “legally marketed” devices.

The bottom line

Coolief might be helpful for some people with osteoarthritis of the knee. Or it might not. Before I recommend this expensive procedure, I’d like to see more and better studies. The ads are dramatic and eye-grabbing, just as they’re intended to be (see my blog on direct-to-consumer ads). Unfortunately, the evidence supporting the benefits of this product is not nearly so impressive.

If you have osteoarthritis of the knee, talk to your doctor about all the options, including cooled radiofrequency ablation. And if you see an arrow sticking out of your knee, stop bowling and seek immediate medical attention.

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Antibiotic-resistant urinary tract infections are on the rise

There is a global crisis of antibiotic resistance, and urinary tract infections (UTIs) may be the canary in the coal mine. UTIs are one of the most common types of infections; at least one in two women and one in 10 men will experience a UTI in their lifetime.

Like many human infections, UTIs are usually caused by bacteria living on or in our bodies, and require treatment with antibiotics. What’s alarming the medical community now is that UTIs are becoming ever harder to treat with common antibiotics.

Antibiotic overuse leads to antibiotic resistance

At some point, most people have taken a course of trimethoprim/sulfamethoxazole (Bactrim) or ciprofloxacin (Cipro), two common antibiotics used for UTIs. However, in the last few years it has become clear that the likelihood these antibiotics will kill most UTIs is dropping rapidly. You may have read the recent, frightening New York Times article reporting one in three uncomplicated UTIs in young healthy women are Bactrim-resistant and one in five are resistant to five other common antibiotics. Pretty scary, since we (the medical community) used to feel confident that writing a prescription for Bactrim was a sure recipe for cure.

How is it that we are losing the antibiotic war with bacteria? Though many things drive bacterial resistance, giving antibiotics to animals and antibiotic overuse in humans top the list.

We use a lot of antibiotics in humans — too much, and not always for the right reasons. When we prescribe antibiotics for viral illnesses like a cold, the flu, or common sinusitis, we create a massive shift in the body’s bacteria for no good reason (antibiotics are useless against viral infections).

Antibiotics can be lifesaving when needed. But when they aren’t needed, they kill good and bad bacteria alike, putting the body’s bacteria under intense pressure to survive. And, bacteria are real survivors! Under pressure, bacteria exchange genetic material and evolve, gaining survival traits like the ability to pump out, break down, or avoid antibiotics we want to use against them. Without antibiotic tools to kill them, these bacteria can attack us freely, and sometimes win.

Carefully targeted antibiotic treatment for urinary tract infections

So what do we do now? As a society and as individuals, we should reduce and carefully target antibiotic use. Both physicians and patients should be aware of the grave potential to lose effective antibiotics for all infections — even simple UTIs. It’s an opportunity that empowers individuals to have informed conversations with their doctors. Every time your doctor prescribes an antibiotic, ask: Do I need this? Why? Is there an antibiotic-free alternative? Talking about it might be enough to meaningfully reduce inappropriate antibiotic use.

If you’re having UTI symptoms like burning with urination, more frequent urination, bloody or cloudy urine, low abdominal pain, or fever, you should see a medical provider to get tested. You’ll have to urinate into a container and the medical office will test for products of bacterial metabolism. Make sure to tell your provider if you’ve had UTIs before, and what antibiotic you took. If you have a history of antibiotic-resistant infections, share that, too. There are alternatives to Cipro and Bactrim, but antibiotic choices are limited.

If you’re diagnosed with a UTI, your provider may prescribe an antibiotic without additional testing. Or, they might do a urine culture to test the bacteria against specific antibiotics before deciding which one to prescribe. This will become more common as antibiotic resistance increases. Antibiotic testing involves growing a sample of urine in a petri dish, finding the bacteria causing infection, and testing them against a range of antibiotics to see which ones kill the bacteria best. This process takes time and money, but it’s important to get the right treatment for your infection. While you wait for the results, taking over-the-counter analgesics like acetaminophen or ibuprofen and drinking more water can help to relieve UTI pain and discomfort.

If antibiotic resistance continues to grow, more people will need intravenous treatment for UTIs we used to cure with simple oral antibiotic courses. We’re also likely to see more complications, like kidney infections and sepsis, arising from ineffective treatment.

An ounce of prevention

Unfortunately, most UTIs are not completely preventable, and are caused by differences in the structure or function of the urinary tract and immune system. But there are things you can do to keep healthy. For example, stay hydrated to increase urine production and flush out unwanted bacterial intruders. Good hygiene is also important, but scrubbing away at delicate genital tissues can damage them and create portals for bacteria. Clean your genital area gently with mild soap and water. Postmenopausal women may benefit from vaginal estrogen cream. Finally, eating cranberries and urinating after having sex haven’t been proven to have major benefits, but aren’t likely to hurt, either.

Follow me on Twitter @lisa_xpond

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Too old for the pediatrician? Time to switch doctors

It happens to every young adult: at some point, they become too old for their pediatrician.

When it happens depends both on the young adult and the pediatric practice. Some teens are ready for a change when they become legal adults at 18, tired of sitting with babies in the waiting room. Others want to stay with their pediatrician, and do until the very last minute the pediatrician will let them. As for practices, some have firm rules about when patients need to move on, while others don’t, letting them stay until the early years of their 20s.

Ideally, young adults will have a smooth transition from one health care provider to another: a full and clear hand-off of all the medical and other information needed. Unfortunately, it’s often not so smooth. Many young adults find themselves adrift without a doctor, which can be a particular problem for those with chronic health problems. And many others find themselves sitting in an office with a doctor who knows nothing about them. This situation is often made worse when that young adult doesn’t know enough about their own medical history to get the doctor up to speed.

Below are some actions parents and teens or young adults can take to make sure this transition goes as smoothly as possible.

Help teens build skills and understand their health needs

• By the time your teen reaches high school age (and maybe before), give them time alone with their health care provider. This allows teens to practice self-advocacy and build necessary skills for talking about their health and health care needs.
• If your teen has a chronic health problem, teach them about it. By the time they are 18, or preferably before, they should have a solid understanding of their condition and its implications.
• If your teen takes regular medications, make sure they know the names, doses, and what they are taking them for. Help them learn independence in taking their medications and also in calling for refills. Start this by high school.
• Make sure your child knows all of their allergies. Many teens do not.

Work with your pediatrician and health plan

Plan to start the transition to another doctor at least a year ahead of time — more in some circumstances, such as when a teen has a disability or sees specialists.

• A teen with a disability may need your involvement in their life and health care past the age of 18. Talk to your doctor about whether or not guardianship would be a good idea. Aim to start this conversation by age 16, because the process can take some time.
• Ask your pediatrician when patients need to leave the practice, so you know when you need to get started on the transition. It may take a while to find a doctor and get an appointment. So, start at least a year ahead of time.
• Check with your insurance company about options for primary care practices. Look up practices and practitioners online together. Find out what you can and get recommendations from people you trust — including your pediatrician!
• If your teen sees specialists, get recommendations from them as to which specialists your teen might see as an adult. This is an important conversation to have as you look for primary care practices. It’s best if the new primary care practice is affiliated with the recommended specialist and their hospital.

What will the new doctor need to know?

• You will need to get health records transferred from your pediatrician to the new practice. If you child is 18 or older, he or she will have to make this request, not you. Ideally, request all of the records, perhaps on a disc or thumb drive. What the new doctor needs most are the last few notes in the record (including the last physical, and the latest specialty notes), the vaccination record, and an updated medication and allergy list.
• Make sure your teen knows their family medical history. Write down any medical problems in the family, particularly those of your teen’s parents, siblings, grandparents, and other close relatives. It’s not something families often talk about, and it’s crucial information for your teen’s new doctor.
• See if your pediatrician is willing to reach out to the new primary care provider to do a “warm handoff.” Most are willing and it could make all the difference, especially if there are any special health care needs.

This may seem like a lot, but it’s really not. The key is to start early, and work at it throughout your child’s high school years. If you do, by the time they make the transition from a pediatrician to a new primary care doctor, everyone will be ready — not just your child, but also the new doctor, which puts your child in the best position possible as they take on life — and health care — on their own.

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Should I participate in a cardiac rehabilitation program?

Cardiac rehabilitation (CR), or “cardiac rehab,” is a multifaceted, medically supervised program proven to improve heart health and outcomes in people with certain types of cardiovascular disease. CR revolves around three major components: an individualized exercise and training program, education on topics related to heart health, and stress reduction.

CR is currently recommended for the following diagnoses: angina (chest pain); heart attack with or without angioplasty or bypass surgery; heart failure with reduced ejection fraction (HFrEF); and heart surgery including heart valve procedures or heart or heart/lung transplant. Insurance typically covers CR for these conditions, though copayment, duration, and frequency of treatment may vary depending on the insurance plan.

Benefits of cardiac rehabilitation

The benefits of CR are well supported by long-standing evidence that showed a 20% reduction in heart-related death and illness, and a 28% lower risk for hospital admissions. The risk of nonfatal strokes, heart attacks, and worsening of heart failure symptoms were also reduced. Improvements in quality of life, the ability to carry out day-to-day activities, and measures of depression and anxiety have also been established.

Patient satisfaction with CR services is consistently high. And most patients trace positive lifestyle changes to their participation in a CR program.

What should I expect from CR?

CR is an outpatient program that usually takes place in a medical center or hospital-based facility. It typically includes up to 36 sessions over a three-month period. There is a clear benefit for consistent participation in a CR program: research has shown that people attending at least 25 sessions seem to derive clinically significant benefit compared to those who attended fewer than 25 sessions.

Following a referral by your treating physician, who may be a cardiologist, cardiac surgeon, or your primary care physician, you will contact the CR program to schedule your intake visit. An exercise test is often performed prior to starting CR, but it is not absolutely necessary.

The exercise test will help in the planning of your exercise program. Exercise is performed under monitored conditions where your heart rhythm and blood pressure are regularly checked. In addition to supervised exercise, these sessions also include education about heart-healthy lifestyle changes and counseling to relieve stress and anxiety. It is known that depression is often diagnosed following a heart attack and usually negatively impacts prognosis; data have shown that CR participation helps in diagnosis of depression and can help improve symptoms of depression.

During the intake visit, you will meet the entire program staff. This includes a nurse, a physical therapist or exercise physiologist, and a dietitian or nutritionist. Together, your team will develop an individualized treatment plan (ITP), which provides a baseline risk assessment and clear, specific exercise, lifestyle, and educational objectives (such as quitting smoking or controlling anxiety). If necessary, your CR team may suggest additional assessments or referrals, for example, to a sleep apnea specialist or mental health professional.

You’ll participate in two to three sessions per week, and your ITP will be re-evaluated and adjusted as needed every month. For example, your exercise threshold may be increased, or your diet recommendations may be adjusted to include less carbohydrates.

During your final visit, your team will assess your functional improvement, weight loss, smoking status, and improvements in your cholesterol levels and HbA1c (a measure of blood sugar), if you have diabetes.

CR participants are strongly encouraged to continue their exercise routine and new lifestyle habits on their own after “graduating” out of the CR program.

What if my doctor doesn’t refer me for cardiac rehabilitation?

Despite the proven benefits of CR, only approximately one in five eligible patients participates in a CR program. If you are eligible for CR — if you have been treated for a heart attack, have received a coronary stent, or have undergone cardiac surgery such as a bypass or valve procedure — make sure you talk to your doctor about the role that cardiac rehabilitation could play in your recovery.

Your cardiac surgeon might recommend waiting four weeks before you start exercising. While it is important to follow that recommendation, you can initiate the paperwork and enrollment process before then, so you’re ready to start your CR program as soon as you are cleared by your surgeon.

What about home-based CR?

The American Heart Association (AHA), American College of Cardiology (ACC), and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recently released a statement about home-based CR. Based on the data, they stated that for appropriate, low- to moderate-risk patients, home-based CR is equivalent to center-based programs. Carefully selecting appropriate candidates reduces the risk of at-home CR, which involves an unsupervised exercise component. At this time, only a few programs offer a home-based option, and those that do often require that initial risk assessment and development of an ITP happen at a medical center.

In the coming months and years, the development and spread of mobile technologies will allow remote monitoring and guidance of exercise and education sessions. Eligible patients will be able to communicate and do their cardiac rehab on their own schedule, without having to miss work or arrange for transportation. CR staff will be able to reach a larger group of patients, and home-based programs are likely to enroll an increasing number

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Ranitidine (Zantac) recall expanded, many questions remain

As anticipated, recall of the popular heartburn medicine ranitidine (Zantac) has expanded. But we still have more questions than answers.

As I mentioned in my original blog post on this topic, the online pharmacy Valisure, which originally alerted the FDA to the issue, found what they called “extremely high levels” of the probable cancer-causing substance N-nitrosodimethylamine (NDMA) in ranitidine products.

The FDA has indicated that its own preliminary testing has detected low levels of NDMA in ranitidine.

Testing methods may have influenced NMDA results

The FDA has clarified that the testing method that found the “extremely high levels” of NDMA applied high heat, at a level much higher than normal body temperature. In other words, the testing did not reflect typical conditions under which the medication would be stored or taken.

The FDA is asking all companies that manufacture ranitidine, as well as other similar medications (both H2 blockers, the class of drugs to which ranitidine belongs, and proton-pump inhibitors, or PPIs, a different class of drugs used for similar conditions), to test their products using lower heat closer to normal body temperature. So far, there is no indication that these other products are affected; the FDA is likely asking for these tests only as a precaution.

As of now, the FDA has allowed ranitidine to remain on the market. Still, some manufacturers have issued voluntary recalls and some pharmacies have pulled it off the shelves.

FDA estimates ranitidine NMDA risk with other medications

The FDA has not yet released the results of its own tests of ranitidine. But they previously estimated the likely impact of NDMA found in another class of medications, called angiotensin receptor blockers, on the risk of cancer. That estimate provides some context for the current circumstances.

Angiotensin receptor blockers, including the drug valsartan (Diovan), are used to treat high blood pressure and other heart conditions. They were recalled beginning last year due to the presence of NDMA and other related impurities. The FDA estimated that, if 8,000 people took the highest dose of valsartan containing NDMA every day for four years, there would be one additional case of cancer over the lifetimes of these 8,000 people.

Currently, we do not know how the amount of NDMA found in ranitidine compares to the amount found in valsartan.

Until we know more, the best course of action if you are taking ranitidine is to talk to your doctor about whether treatment is still needed. For some conditions, the benefits likely outweigh the risks. Although some ranitidine products remain available, consider alternative medications such as cimetidine (Tagamet) or famotidine (Pepcid) if you need long-term treatment.

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Gene testing to guide antidepressant treatment: Has its time arrived?

Depressive disorders are among the most common conditions that disrupt lives. Fortunately, medications, psychotherapies, and lifestyle changes are usually successful in treating depression and related disorders, even if symptoms are not entirely eliminated. Sometimes people don’t gain sufficient relief from treatment, or must try several medications before finding one that works well. In an age of exciting advances, including brain imaging and genetic testing, many doctors and patients reasonably hope that new technologies will offer answers. And in fact, for antidepressant choice, several companies sell genetic testing as a means to guide treatment. But do these tests work?

Genes, gene testing, and depression

Genes determine some of our risk for depression and some of our response to treatment. However, no single gene or small number of genes determines much of either in the general population. And the few genes used in the current commercial test panels do not appear to be the key genes determining risk or response. Some of the genes tested are related to drug metabolism. These genes can affect drug levels in the blood, but generally don’t predict clinical response. Other factors, including age, diet, hormonal state, gut bacteria, and any other concurrently taken drugs, are far more important in determining how a person metabolizes a drug and responds to treatment.

Most people with depression improve with careful evaluation of all of these factors, appropriate antidepressant choice and dosing according to expert guidelines, as well as follow-up care to monitor treatment response and address any side effects. Currently, there is no scientific evidence that gene tests are needed or would be helpful as part of those assessments.

What do the studies tell us?

A dozen studies focusing on patients with depressive disorders have reported outcomes from using commercially available gene test panels to guide antidepressant choice. Most studies were completely unblinded — that is, doctors and patients knew a special test was given. Even with that bias, the use of gene results showed no evidence of effectiveness. A few studies were partially blinded, but doctors and patients still knew some patients got a special test. In these studies, too, the tests failed to show value on their key measures of efficacy.

Notably, many patients had not responded well before entering a study because they were receiving inappropriate treatments. They improved when switched to more standard treatments. However, the same changes would have been made without guidance from the test if the treating clinicians had simply followed good practice, rather than getting an unproven and expensive genetic test. And our ongoing review of newer studies on these tests suggests similar flaws and no further evidence favoring their use.

What do experts say about using gene tests to determine treatment for depression?

Against this background, experts with no financial interest in genetic testing have repeatedly recommended that genetic tests should not be used in choosing treatments for depression (see here and here). The American Psychiatric Association convened a task force that reviewed the evidence and agreed: the tests should not be ordered.

Recently, the FDA advised that the tests had no proven value and should not be used. Then they went two steps further, stating that use of the tests could lead to inappropriate treatment choices that might harm patients. Additionally, the FDA sent a warning letter to one company and has contacted others selling the tests, advising them that they cannot legally make specific recommendations to clinicians or patients based on their test results.

Why are gene tests so appealing?

Genetic testing is appealing, both to vulnerable patients and time-constrained doctors. And it is vigorously marketed to both parties by the companies that sell it: through news reports, websites, television, and magazines, and to doctors in their offices. There are few restraints that hold that marketing to the facts, yet the facts are clear in evidence summarized by numerous experts and agencies. Currently available genetic test panels have no proven value for choosing antidepressant treatment, and their use risks providing inappropriate care. So, while gene testing can be very useful for some other conditions, notably some cancer treatments, that success does not yet apply in treating depression. Perhaps this will change with more research, but appropriate tests are years away.

If gene tests aren’t effective, what is?

In the meantime, there are many good and effective actions to take if treatment is not working well. You and your doctor can

• review your symptoms and diagnosis
• review side effects of other medications you take to see if this is part of the problem
• double-check that you are taking the medications correctly
• consider other factors that might affect your response to treatment, such as alcohol, marijuana use, or other substances
• change the doses or types of medications based on guideline recommendations, or seek a consultation with an expert.

When a medication change is needed, the clinician treating you should follow available guidelines (such as these) or help you obtain a consult from a mental health professional who is more knowledgeable about psychiatric medications. Psychiatry consultations are available at most hospitals and clinics; some hospitals offer these consults by phone or through their websites.

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